Download D-Lactic Acidosis

Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
© Williams & Wilkins 1998. All Rights Reserved.
Page 1 of 20
Volume 77(2), March 1998, pp 73-82
D-Lactic Acidosis: A Review of Clinical
Presentation, Biochemical Features, and
Pathophysiologic Mechanisms
[Article]
Uribarri, Jaime MD; Oh, Man S. MD; Carroll, Hugh J. MD
From the Department of Medicine (JU), Mount Sinai Medical Center,
New York, New York; and Department of Medicine (MSO, HJC), State
University of New York Health Science Center at Brooklyn, Brooklyn, New
York.
Address reprint requests to: Jaime Uribarri, MD, Mount Sinai Medical
Center, One Gustave Levy Place, New York, NY 10029. Fax: 212-3699330.
Introduction
D-lactic acidosis as a disease of humans was first described in 1979 [51], although it had been
known as a disease of ruminants for decades [22]. Following this initial report, numerous other
cases of this syndrome have been described
[6,8,13,16,24,28,29,31,33,35,36,37,39,40,41,45,46,48,49,54,55,58,59,60,61,63,64,67].
The clinical
presentation is characterized by episodes of encephalopathy and metabolic acidosis which are
thought to be due to the absorption of d-lactic acid and other unidentified chemicals produced by
bacterial fermentation in the colon. Initially d-lactic acidosis was thought to be due solely to
overproduction of d-lactic acid because it was thought that d-lactic acid was not metabolized by
humans [64]. The subsequent finding that normal subjects have an enormous capacity to
metabolize d-lactic acid suggests, however, that the development of d-lactic acidosis requires
impaired ability to metabolize d-lactic acid in addition to excessive production [52].
In this report we present a case of d-lactic acidosis previously reported by us [53], followed by
a review of other cases of d-lactic acidosis reported in the literature. The purpose of this review is
to define the clinical and biochemical features of d-lactic acidosis, and ultimately to shed some
light on the pathogenetic mechanism of the disease. Last, we review the literature dealing with
the metabolism of d-lactic acid in humans to explore the possible role of impaired utilization of dlactic acid in the pathogenesis of d-lactic acidosis.
Illustrative Case
A 30-year-old white man was brought to the emergency room by his mother because of
mental confusion, disorientation, slurred speech, and delirium [53]. Staggering gait and nystagmus
were noted on physical examination. The pertinent laboratory findings on arrival at the emergency
room were: arterial blood pH, 7.14; pCO2, 21 mmHg; pO2, 112 mmHg; HCO3, 7 mmol/L; serum
creatinine, 2.2 mg/dL; BUN, 18 mg/dL; serum glucose, 85 mg/dL, serum sodium, 143 mmol/L;
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 2 of 20
serum chloride, 110 mmol/L; serum osmolality, 286 mOsm/L; and the serum anion gap, 26
mmol/L. Urinalysis showed a pH of 5.5, a specific gravity of 1.025, a few calcium oxalate crystals,
and was otherwise unremarkable. Serum lactate concentration was 1.6 mmol/L and Acetest was
negative in serum and urine. The patient subsequently denied ingestion of any drugs, toxins, or
ethanol. Treatment with sodium bicarbonate increased blood pH, but the patient remained
confused and disoriented. Over the next 12 hours, the patient gradually recovered from neurologic
dysfunction and from acidosis, with normalization of the anion gap.
The medical history obtained subsequently revealed that the patient had been in good health
until the development 3 years before of small bowel infarction due to superior mesenteric vein
thrombosis, which required resection of most of the small bowel except for 13 inches of the
terminal ileum. Following surgery, he developed malabsorption syndrome, manifested by diarrhea
and weight loss. His gastroenterologist prescribed Lactobacillus acidophilus tablets as a treatment
for diarrhea. Soon after he was started on Lactobacillus acidophilus, the patient began
experiencing episodes of neurologic symptoms similar to those described before. These attacks
occurred first once a month, and then at increasingly shorter intervals. The attacks always
occurred after a meal, and the symptoms subsided spontaneously after a variable period of time.
Literature Review
A computerized literature search was performed using the headings "d-lactic acidosis" and "dlactate encephalopathy" from 1979 until 1997. This initial search was supplemented by review of
all the references contained in these papers. We have arbitrarily defined d-lactic acidosis as
metabolic acidosis accompanied by increase in serum d-lactate in excess of 3 mmol/L. In contrast,
l-lactic acidosis is commonly defined by a serum level of lactate greater than 5 mmol/L [44]. The
rationale for using a lower serum level for definition of d-lactic acidosis than that for l-lactic
acidosis is that the renal threshold for d-lactate is much lower than that for l-lactate, so that
clinically significant metabolic acidosis may occur at much lower serum levels of d-lactate. Using
this definition, we were able to collect 29 cases of d-lactic acidosis
[6,8,13,16,24,31,33,35,36,37,39,40,41,45,46,48,49,51,54,58,59,61,63,64,67]
from 29 reports
[6,8,13,16,24,28,29,31,33,35,36,37,39,40,41,45,46,48,49,51,54,55,58,59,60,61,63,64,67].
We have not
included in this series a case of d-lactic aciduria without acidemia and with a plasma d-lactate
level of 0.6 mmol/L reported in 1977 [23] in a mentally retarded infant without apparent intestinal
disease and thought to be the result of an inborn error of metabolism, nor we have included a
child with the short bowel syndrome with significant lactic aciduria defined by chromatographic
analysis of urine but without measurement of the specific stereoisomer of lactic acid [47]. We have
also omitted several cases [2,19,25,56,57] of acidosis and/or encephalopathy described in patients
with intestinal bypass before the syndrome of d-lactic acidosis was recognized; the clinical
presentation in these patients suggests the syndrome of d-lactic acidosis but the diagnosis cannot
be confirmed because the levels of d-lactic acid were never measured.
Each report was analyzed for the presence and characteristics of the following variables: sex
and age of the patient, cause of short bowel syndrome, neurologic manifestations, serum
electrolytes, blood pH, anion gap, renal function, peak serum d-lactate concentration, peak
urinary d-lactate concentration, factors precipitating the episodes, and treatment.
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 3 of 20
A second computerized search was performed using the heading "d-lactic acid metabolism."
This search was supplemented by review of all the references contained in these papers.
Results
As shown in Table 1, the disease occurred more often in males than females (18:11). The
average age of the patients was 30 +/- 17 years with a range from 18 months to 60 years, and
the predominant underlying condition was the short bowel syndrome due to either surgical
resection of the intestine (17 cases) or intestinal bypass surgery for treatment of obesity (10
cases). In 1 case the syndrome was acutely precipitated by the accidental placement of a feeding
tube into the colon instead of the stomach [49]. In another case the underlying abnormality was
not clear but the patient was known to have chronic pancreatitis and had been receiving
pancreatic enzymes in the past, and it is likely that he suffered from malabsorption secondary to
exocrine pancreatic insufficiency [45].
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
Page 4 of 20
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 5 of 20
Table 1. Characteristics of 29 patients with d-lactic acidosis, from previous reports
A description of renal function was given for 12 of the patients: in 8 patients the BUN was
described as normal [13,24,36,58,64,67], 1 patient had moderate azotemia and a creatinine
clearance of 30 mL/min [64], 1 had a serum creatinine of 2.2 mg/dL [45], and 2 patients had endstage renal disease and were receiving maintenance hemodialysis [33,63].
As seen in Table 2, the neurologic abnormality that was present in every case was altered
mental status. Other neurologic abnormalities were slurred speech, confusion, inability to
concentrate, somnolence, hallucinations, clumsiness, weakness, ataxia, unsteady gait, nystagmus,
excessive irritability, and abusive behavior. The attacks were episodic, lasting from a few hours to
several days. Electroencephalograms during encephalopathic episodes showed bilateral, diffuse,
high-voltage slow waves without focal abnormality, which normalized after attacks [8,24,51,63].
Partial ptosis has been described during an attack in 1 patient [36] and asterixis in another patient
[24].
The presence of d-lactate in the cerebrospinal fluid was reported in 2 patients; the levels
were the same as the serum levels [40,61].
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 6 of 20
Table 2. Prevalence of neurologic symptoms and signs
Symptoms were aggravated by excessive oral food intake and alleviated after caloric
restriction [6,31,40,46,49,54,58,61]. In fact, craving for and excessive consumption of carbohydrates
have been noted in several reports [8,40,61]. In 1 patient, symptoms seem to have been
precipitated by the use of medium-chain triglycerides [37] which have been recommended to
improve the nutritional status in patients with the short bowel syndrome.
Acidosis was present in all patients, and it was of quite variable degree, as shown in Table 3.
The average serum anion gap was increased, but some values were within the normal range. The
mean peak serum d-lactate concentration was 8 +/- 4 mmol/L. The amount of d-lactate in the
urine was variable, with the highest concentration reported as 200 mmol/L.
Table 3. Serum electrolytes corresponding to the lowest blood pH
In those cases in which bacteriologic analysis of fecal flora was performed, it showed almost
without exception a marked predominance of Gram-positive anaerobic organisms including a
variety of lactobacillus, bifidobacterium, and eubacterium, which have been shown to produce dlactate in vitro [6,33,35,46,54,59,63,65]. Evidence for the production of d-lactate by intestinal
bacteria is contained in a number of reports [6,16,35,46,54,59,64].
(Table 4) summarizes the information on metabolism of d-lactate by humans. The data show a
substantial rate of metabolism of d-lactate [1,11,17,18,32,42,52,72].
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 7 of 20
Table 4. D-lactate metabolism in humans
(Table 5) summarizes the modalities of treatment attempted in each case report of the
syndrome.
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 8 of 20
Table 5. Modalites of treatment in 29 patients with d-lactic acidosis, from previous reports
Discussion
Clinical manifestations
The characteristic manifestations of d-lactic acidosis are recurrent episodes of encephalopathy
and metabolic acidosis occurring in a patient with the short bowel syndrome. Neurologic
abnormalities are always present although their nature varies from patient to patient. Common
features include slurred speech, confusion, inability to concentrate, somnolence, hallucinations,
clumsiness, weakness, ataxia, unsteady gait, nystagmus, excessive irritability, and abusive
behavior. These episodes last from a few hours to several days.
Metabolic acidosis is always present but its severity varies from patient to patient and for a
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 9 of 20
given patient from 1 attack to another. The serum anion gap is usually high at the onset of
symptoms but the increase in the anion gap tends to be less than the decrease in the serum
bicarbonate concentration; in l-lactic acidosis the increase in the anion gap is usually greater than
the reduction in bicarbonate [50]. The discrepancy could be explained by 2 factors: the
significantly lower renal threshold for d-lactate (<1 mmol/L) than for l-lactate [52], and the loss of
the sodium salt of d-lactic acid in the stool (the H+, but not the organic anion is reabsorbed or
reacts with secreted HCO3 in the lumen) [30]. Moreover, these patients can have baseline
hyperchloremic acidosis because of chronic diarrhea with loss of HCO3 in the stool. One patient
has been described [36] who might have had underlying renal acidification defects. Several
patients have been reported [2,19,25,56,57] with the characteristic neurologic findings of d-lactic
acidosis but without systemic acidosis.
Chemistry of l- and d-lactic acids
L- and d-lactate are optical isomers which differ only in the position of the alpha-hydroxy
radical. Both compounds are produced from, and metabolized to, pyruvate by the enzyme lactic
dehydrogenase (LDH). The latter enzyme is isomer-specific; the production of d-lactate requires
d-LDH and that of l-lactate, l-LDH. Mammals have only the enzyme l-LDH.
Small quantities of d-lactate may be found normally in the blood [4] and excreted in the urine
This d-lactate is probably formed in the body through the methyl-glyoxal pathway [65] or
[38].
within the gastrointestinal tract by bacterial fermentation [10]. Other potential sources of d-lactate
are dietary intake [53] and administration for medical use. Humans ingest d-lactate frequently
[53];
fermented fruits and vegetables such as pickles, yogurt, and sauerkraut contain both l- and
d-lactic acid. Lactated Ringer solution and peritoneal dialysate also contain racemic mixtures of
both isomers in the same proportion. Recently, it has been suggested that the metabolism of
propylene glycol, an agent frequently used in medications and food, can lead to generation of dlactate [9].
The predominant form of lactate normally present in the blood of humans and other
vertebrates is l-lactate, which is derived from pyruvate by the action of l-LDH.
Metabolism of d-lactate in humans and animals
When d-lactic acidosis was first described in humans in 1979 [51] it was thought that
mammals metabolize d-lactate very slowly. It is now clear, however, through the evidence
summarized in Table 4, that normal humans metabolize d-lactate efficiently. The most complete
data are those of Oh and colleagues [52], who showed that normal subjects were able to
metabolize d-lactate at a rate of 1.52 mmol/kg per hour with a serum level of 5.2 mmol/L, when
dl-lactate was infused intravenously at a rate of 1.92 mmol/kg per hour for each isomer. At such a
rate a person weighing 70 kg can metabolize about 2,500 mEq of d-lactate per day. These data
are in agreement with those in other studies in humans [1,11,17,18,32,42,72] and in other mammals
such as rats [26,27], rabbits [21], dogs [14], and baboons [12].
Smith and colleagues [62] have argued, based on their studies in rats and humans, that
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 10 of 20
mammals lack a significant ability to metabolize d-lactate. However, a review of their data
shows strong evidence that rats metabolize d-lactate efficiently; when d-lactate was given
intravenously, it disappeared rapidly from the circulation and only 25% was excreted in the urine.
Moreover, ligation of renal arteries and veins did not alter the rate of elimination of d-lactate from
the blood. Their data in a normal human subject have a number of inconsistencies. For example,
while the total administered dose of d-lactate was 2.15 mmol, the plasma level was 1 mmol/L, an
outcome that is impossible since the space of distribution of d-lactate should be at least equal to
the extracellular space.
In summary, most of the data available in the literature strongly suggest that d-lactate is
efficiently metabolized by mammals [1,11,12,14,17,18,21,26,27,32,42,51,72]. Since mammals lack dLDH, metabolism of d-lactate must use alternative routes. The enzyme likely to be responsible for
metabolism of d-lactate in mammals is d-2-hydroxy-acid-dehydrogenase, a mitochondrial enzyme
that converts d-lactate to pyruvate and is found in a variety of animal tissues [7,68]. This enzyme
is a nonspecific flavoprotein, and its substrates include d-lactic acid as well as other d-2-hydroxy
acids [20]. The enzyme may be important for the synthesis of protein and is active over only a
limited pH range [20,68].
Renal handling of d-lactate
The renal threshold for d-lactate is much lower than that of l-lactate, and a significant
proportion of d-lactate infused intravenously escapes in the urine [52]. Lactate is normally
reabsorbed by a sodium-lactate contransporter, but it is not clear whether there are different
transporters for each isomer or if the difference in reabsorption is the result of different rates of
metabolism after reabsorption into the tubules [69]. The fact that l- and d-lactate compete with
each other for renal tubular reabsorption suggests that they both utilize the same transporter [52].
Pathogenesis of d-lactic acidosis
The syndrome of d-lactic acidosis is thought to be the result of the production and absorption
of d-lactic acid from the intestine. D-lactic acid production results when carbohydrate
malabsorption in the small bowel leads to increased delivery of carbohydrates to the colon with
subsequent fermentation by colonic bacteria to l- and d-lactate. Only d-lactate accumulates
because of its slower metabolism. An increased delivery of substrate to the colon is a constant
finding in these patients. The latter point is clearly illustrated by the patient [49] who developed
the syndrome following the accidental placement of a feeding tube directly into the colon; rapid
reversal of the acidosis followed cessation of feeding and removal of the tube.
The course of events described above has been clearly documented in d-lactic acidosis
observed in ruminants overfed with grains [22]. In those cases it has been shown that acidosis is
the result of the increased production of d-lactic acid by bacterial fermentation and its subsequent
absorption into the blood. Large amounts of l- and d-lactic acid are produced by bacteria but only
the d-isomer accumulates since absorbed l-lactic acid is more rapidly metabolized. When the rate
of absorption of d-lactic acid into the body overwhelms the body's metabolic capacity to
metabolize it, acidosis develops.
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 11 of 20
The presence of abnormal bacterial flora in the colon is also essential for the development of
the syndrome. Stool cultures have invariably shown a marked predominance of Gram-positive
anaerobes such as species of lactobacillus which are known to produce d-lactic acid in vitro.
Lactobacilli produce not only d-LDH but also dl-lactate racemase which could potentially explain
interconversion of d- and l-lactate [35]. Alteration of the flora probably occurred following
ingestion of lactobacillus in 1 case [51] and following antibiotic administration in 2 other cases
[13,24].
Mild overproduction of d-lactic acid may not be unusual in patients with the short bowel
syndrome. For example, Thurn et al [66] have shown that in a group of 33 patients with jejunoileal
bypass, 9 (27%) patients had plasma d-lactate levels greater than 0.5 mmol/L (range, 0.7-11.5
mmol/L). Moreover, in 470 randomly chosen hospitalized patients, plasma d-lactate levels were
greater than 0.5 mmol/L in 13, and 60% of these had a history of gastrointestinal surgery or
disease. Hove et al [34] measured the fecal d- and l-lactate concentration in 100 nonselected
patients at a referral center for gastrointestinal disorders and found that 21% had high d-lactate
concentrations; the levels were high in 73% of the patients with active inflammatory bowel
disease, in 33% of those with malabsorption syndrome, and in only 5% of patients with neither of
these 2 conditions. Bustos et al [5] measured d-lactic acid in blood, urine, and fecess in 11
patients with the short bowel syndrome and showed that the levels in the stool were increased in
9 patients but that levels were undetectable in the urine in all 11 and in the blood of 10 of these
patients (the lower limit of detection of d-lactic acid is not given). Bongaerts et al [3] studied a
group of 8 patients with the short bowel syndrome and demonstrated that d-lactate is frequently
present in serum and urine of these patients even in the absence of acidosis.
It is not known why d-lactic acidosis develops intermittently and not with every meal although
the abnormal colonic flora, once developed, must be present constantly. If malabsorption
syndrome with increased delivery of nutrients to the colon led immediately to osmotic diarrhea,
there might not be a sufficient amount of substrate in the colon to produce clinical d-lactic
acidosis. Hence, colonic stagnation might be another important contributing factor. The fact that
the syndrome has not been described with greater frequency in patients with malabsorption
syndrome not related to a short bowel may also be explained by the limited substrate availability
in these other conditions. In general, malabsorption syndrome is more severe in the short bowel
syndrome.
In vitro studies with stool homogenates have shown that the formation of d-lactic acid is
stimulated by low pH and inhibited at pH 6.5 or higher [6]; the suggestion has been made that
increasing the luminal colonic pH by dietary supplements of CaCO3 and MgCl2 may potentially be
used to diminish intestinal production of d-lactic acid [6].
Another noteworthy point is the delay in the appearance of symptoms; patients with intestinal
resection or bypass surgery usually develop d-lactic acidosis after a delay of several months to a
few years. It has been suggested that a change in the intestinal flora occurs during this time [55].
It is useful to estimate the likely rate of d-lactate production with usual food in order to
determine whether a defect in d-lactate metabolism plays a role in the pathogenesis of d-lactic
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 12 of 20
acidosis. For this estimation, we make the following assumptions. First, the daily caloric intake
is 3,000 calories. Second, one-half of the calories ingested are absorbed in the small intestine and
the other half delivered to the colon. Third, one-half of the daily caloric intake comes from 1 big
meal such as dinner. Fourth, one-half of the entire caloric intake is in the form of carbohydrates.
Fifth, all the carbohydrates delivered to the colon are converted by bacteria to l- and d-lactate in
equal proportions. In this case, if 1,500 calories are ingested during dinner, and 750 calories are
delivered to the colon, 375 calories will be as carbohydrates and 375 as some other nutrients.
These 375 calories would come from 94 g of carbohydrates, which then would produce 522 mmol
of d-lactate and 522 mmol of l-lactate. If we further assume that 522 mmol of d-lactate was
produced over a 6-hour period, the production rate will be less than 100 mmol/hour. Since normal
humans can metabolize d-lactate at a rate greater than 100 mmol/hour with modest increase in
serum concentration [52], one might argue that impaired metabolism is a prerequisite for the
production of d-lactic acidosis.
On the other hand, it is also possible that d-lactic acidosis occurs only when the food intake is
grossly excessive so that the rate of d-lactate production could exceed the rate estimated above.
It is also possible that the rate of d-lactate metabolism is reduced in these patients not because of
any specific metabolic defect but as the result of generalized diminution in metabolism due to
chronic malnutrition. If there is a specific mechanism of this impaired ability to metabolize dlactate, it is currently unknown. Metabolism of d-lactate in mammals seems to require d-2hydroxy-acid-dehydrogenase, which converts d-lactate to pyruvate [7,68]. This enzyme has been
found in high concentrations in the liver and kidneys of several animal species including humans
[72],
and it is possible that disease of these organs might diminish the ability to metabolize d-
lactate. For example, it has been shown that loading rats with d-lactate over several days
significantly increased the activity of d-2-hydroxy-acid-dehydrogenase in the liver, but that this
increase was much less in rats with chronic renal failure than in control animals [71]. Although
renal function has been described in only a few patients with d-lactic acidosis, some degree of
renal insufficiency is common because volume depletion and calcium oxalate kidney stones are
frequent complications in patients with the short bowel syndrome. Unfortunately, the rate of
metabolism of d-lactate in patients with d-lactic acidosis has not been measured.
Oxalate is a powerful competitive inhibitor of d-2-hydroxy-acid-dehydrogenase [68]. Patients
with the short bowel syndrome frequently have intestinal hyperabsorption of oxalate, and it seems
possible that high plasma and tissue levels of oxalate could inhibit enzyme activity. Low pH, which
also diminishes the dehydrogenase activity [68], could play a role in the diminished metabolism of
d-lactate. The effect of pH on in vivo metabolism of d-lactate has not been investigated fully.
Normal subjects metabolize d-lactate and d-lactic acid equally well [17,18] despite the fact that the
former tends to increase the blood pH and the latter decreases it, but differences in blood pH in
these experiments were quite modest compared with those observed in patients with clinical dlactic acidosis.
Another mechanism by which renal dysfunction might alter d-lactate metabolism is
interference with its renal excretion. The renal threshold for d-lactate is low and the renal
fractional excretion is very high [52]. Impaired renal function or volume depletion may decrease
renal excretion of d-lactate and thereby increase plasma levels.
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 13 of 20
The suggestion has been made that thiamine deficiency played a contributory role in the
pathogenesis of d-lactic acidosis in 1 patient [36] because d-lactic acidosis did not recur after
initiation of thiamine supplementation. However, thiamine deficiency has not been shown to
increase production of d-lactate when an specific enzymatic method has been used to measure
this compound [70].
On the basis of the available evidence we believe that the development of d-lactic acidosis
requires the following conditions:
1) Carbohydrate malabsorption with increased delivery of nutrients to the colon,
2) Colonic bacterial flora of a type that produces d-lactic acid,
3) Ingestion of large amounts of carbohydrate,
4) Diminished colonic motility, allowing time for nutrients in the colon to undergo bacterial
fermentation, and
5) Impaired d-lactate metabolism.
Mechanisms of neurologic manifestations
Two main hypotheses have been proposed to explain the neurologic manifestations of the
syndrome: 1) d-lactate itself is toxic to the brain, and 2) unknown compounds produced along
with d-lactate are toxic to the brain. Indeed, compounds such as formate, histamine, ethanol,
tyramine, and endotoxin have been found in the rumen of cattle with d-lactic acidosis [22], and
excessive urinary excretion of hydroxyphenyllactic and phenylacetic acids [8] has been observed in
patients with this condition. The role that each of these compounds may play in causing the
neurologic abnormalities is uncertain but it is clear that ethanol is not responsible for the
symptoms. Although the patients appear drunk, serum levels of ethanol have been normal.
D-lactate can penetrate into the central nervous system by simple diffusion and can thus
reach high concentrations in the brain [43]. Although it has been hypothesized that d-lactate may
accumulate in the brain because of the low local level of catabolizing enzyme [51], levels of dlactate in the cerebrospinal fluid have been found to be equal to those in the blood [40,61].
Moreover, the correlation between plasma d-lactate levels and severity of symptoms is poor.
Thurn et al [66] found that 16 of 33 patients with jejunoileal bypass reported symptoms consistent
with d-lactic acid encephalopathy but only 9 of them had high plasma levels of d-lactate, while
some individuals with high plasma d-lactate levels did not have symptoms. The fact that some
patients present with encephalopathy but without high plasma d-lactate levels strengthens the
suggestion that the encephalopathy results from toxins which may be produced simultaneously
with d-lactic acid. A further argument against a direct role for d-lactate in the alteration of mental
status is that normal subjects who received an infusion of d-lactate did not develop any neurologic
symptoms despite the attainment of serum levels up to 6 mmol/L in 1 study [52] and up to 3.5
mmol/L in another study [17].
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 14 of 20
Acidosis itself is not likely to be responsible for the neurologic manifestations since patients
with other types of acidosis of comparable or greater severity do not present such manifestations.
It could be argued, however, that the abnormal pH might have some role in the toxic effect of dlactate or other chemicals in the brain since patients with d-lactic acidosis usually have significant
metabolic acidosis. It is also probable that d-lactate is harmful to the central nervous system only
in the presence of another metabolic defect, such as deficiency of certain vitamins, which might be
present in patients who develop the syndrome but not in others [15]. Interference on pyruvate
metabolism by d-lactate has been postulated based on observation of clinical similarities between
d-lactic acidosis and inherited or acquired abnormalities of pyruvate metabolism [15].
Diagnosis
Increased anion gap and rapid onset and recovery are characteristic features in d-lactic
acidosis as in other organic acidosis. However, the critical elements that raise suspicion of this
diagnosis in a patient with acidosis are 1) increased serum anion gap with normal lactate levels
measured by conventional techniques and negative Acetest, 2) presence of short bowel syndrome
or other forms of malabsorption syndrome, 3) acidosis that is preceded by food ingestion and that
improves after discontinuation of oral intake of food, and 4) characteristic neurologic findings.
Any patient presenting with acidosis and 1 or more of any of the above clinical clues should be
strongly considered to have d-lactic acidosis, and urine and serum samples should be obtained for
measurement of d-lactic acid. The diagnosis of d-lactic acidosis is confirmed by finding high levels
of d-lactate in urine and/or in serum [51]. We have defined d-lactic acidosis as a metabolic acidosis
accompanied by a serum d-lactic acid greater than 3 mmol/L. Although there may not be
universal agreement about this quantitative definition of d-lactic acidosis, we believe it makes
sense since a lower level of d-lactic acid may be present in serum of patients with malabsorption
syndrome [3,5,66] but it is unlikely to be the cause of an associated acidosis. D-lactate is measured
enzymatically using a specific d-lactic dehydrogenase in the assay [51]; kits to measure d-lactic
acid in serum and urine can be obtained from Boehringer Mannheim, (Indianapolis, IN) and can be
adapted easily to any clinical laboratory. While waiting for the results of these measurements, the
patient should receive no food by mouth and should be given intravenous dextrose solutions as a
source of calories; the rapid improvement of acidosis on this regimen is highly suggestive of the
diagnosis of d-lactic acidosis.
Titration of an increased amount of organic anions in the urine may be an important clue that
suggests this diagnosis [51], but unfortunately this measurement is not available in commercial
clinical laboratories.
Modalities of treatment
Treatment modalities that have been tried can be grouped into the following categories and
are described in detail in Table 5: 1) attempts to alter the abnormal intestinal flora with the
administration of oral antibiotics and recolonization of the intestine by the oral administration of a
bacterial flora called "Julia flora" [60]; 2) attempts to diminish the quantity of substrate for
intestinal fermentation by prolonged oral fasting with simultaneous intravenous alimentation
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
[40,54,64],
Page 15 of 20
use of low-carbohydrate diets, or use of enteral formulas containing fructose or
starch instead of glucose as the main source of carbohydrates [46,58]; 3) correction of the
underlying abnormality by reanastomosis of the intestine in case of intestinal bypass [16,35]; 4)
nonspecific therapy of acidosis with high doses of bicarbonate [6,46]; and 5) correction of acidosis
and simultaneous clearance of dlactate with hemodialysis [33].
No large series from a single institution has been reported, and most of the therapeutic
modalities are based on the experience of individual practitioners with only 1 or 2 cases with
variable success. The most effective immediate treatment consists of elimination of all oral intake
of food while providing intravenous nutrition. Long-term management consists of carbohydrate
restriction and suppression of the intestinal flora with nonabsorbable antibiotics.
Antibiotics control symptoms and prevent recurrences of the syndrome in most patients, but
in some patients acidosis has recurred despite their continuous use [36], and in others the
syndrome may have been precipitated by the use of antibiotics [13]. Therapy with antibiotics has
been complicated by the development of diarrhea [55] or unspecified side effects [31]. Antibiotics
that have been tried include neomycin, vancomycin, ampicillin, kanamycin, and metronidazole.
The optimum duration of antibiotic therapy is unclear since symptoms may recur a few days after
discontinuation of antibiotics in some patients, while others may remain without symptoms after
several years without therapy.
Summary
This report describes a case of d-lactic acidosis observed by the authors and then reviews all
case reports of d-lactic acidosis in the literature in order to define its clinical and biochemical
features and pathogenetic mechanisms. The report also reviews the literature on metabolism of dlactic acid in humans.
The clinical presentation of d-lactic acidosis is characterized by episodes of encephalopathy
and metabolic acidosis. The diagnosis should be considered in a patient who presents with
metabolic acidosis and high serum anion gap, normal lactate level, negative Acetest, short bowel
syndrome or other forms of malabsorption, and characteristic neurologic findings.
Development of the syndrome requires the following conditions 1) carbohydrate malabsorption
with increased delivery of nutrients to the colon, 2) colonic bacterial flora of a type that produces
d-lactic acid, 3) ingestion of large amounts of carbohydrate, 4) diminished colonic motility,
allowing time for nutrients in the colon to undergo bacterial fermentation, and 5) impaired dlactate metabolism.
In contrast to the initial assumption that d-lactic acid is not metabolized by humans, analysis
of published data shows a substantial rate of metabolism of d-lactate by normal humans.
Estimates based on these data suggest that impaired metabolism of d-lactate is almost a
prerequisite for the development of the syndrome.
REFERENCES
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 16 of 20
1. Altschule MD, Henneman DH, Holliday P, Goncz RM. Carbohydrate metabolism in brain disease. Arch
Intern Med 98: 35-38, 1956. [Context Link]
2. Ayub A, Faloon WW, Heinig RE. Encephalopathy following jejunoileostomy. JAMA 246: 970-73, 1981.
Bibliographic Links [Context Link]
3. Bongaerts G, Tolboom J, Naber T, Bakkeren J, Severijnen R, Willems H. D-lactic acidemia and aciduria
in pediatric and adult patients with short bowel syndrome. Clin Chem 41: 107-10, 1995. Bibliographic
Links [Context Link]
4. Brandt RB, Siegel SA, Waters MG, Bloch MH. Spectrophotometric assay for d-lactate in plasma. Anal
Biochem 102: 39-46, 1980. [Context Link]
5. Bustos D, Pons S, Pernas JC, Gonzalez H, Caldarini MI, Ogawa K, De Paula JA. Fecal lactate and short
bowel syndrome. Dig Dis Sci 39: 2315-19, 1994. Bibliographic Links [Context Link]
6. Caldarini MI, Pons S, D'Agostino D, DePaula JA, Greco G, Negri G, Ascione A, Bustos D. Abnormal fecal
flora in a patient with short bowel syndrome. An in vitro study on effect of pH on d-lactic acid production.
Dig Dis Sci 41: 1649-52, 1996. Bibliographic Links [Context Link]
7. Cammack R. Assay, purification and properties of mammalian d-2-hydroxy acid dehydrogenase.
Biochem J 115: 55-63, 1969. Bibliographic Links [Context Link]
8. Carr DB, Shih VE, Richter JM, Martin JB. D-lactic acidosis simulating a hypothalamic syndrome after
bowel bypass. Ann Neurol 11: 195-97, 1981. [Context Link]
9. Christopher MM, Eckfeldt JH, Eaton JW. Propylene glycol ingestion causes d-lactic acidosis. Lab Invest
62: 114-18, 1990. Bibliographic Links [Context Link]
10. Clausen MR, Bonnen H, Tvede M, Mortensen PB. Colonic fermentation to short-chain fatty acids is
decreased in antibiotic-associated diarrhea. Gastroenterology 101: 1497-1504, 1991. Bibliographic Links
[Context Link]
11. Connor H, Woods HF, Ledingham JGG. Comparison of the kinetics and utilization of d- and l-sodium
lactate in normal man. Ann Nutr Metab 27: 481-87, 1983. Bibliographic Links [Context Link]
12. Coran AG. The effect of lactated Ringer's solution on blood and urine levels of lactate isomers. J Surg
Res 11: 450-53, 1971. Bibliographic Links [Context Link]
13. Coronado BE, Opal SM, Yoburn DC. Antibiotic-induced d-lactic acidosis. Ann Intern Med 122: 839-42,
1995. Ovid Full Text Bibliographic Links [Context Link]
14. Craig FN. Renal tubular reabsorption, metabolic utilization and isomeric fractionation of lactic acid in
the dog. Am J Physiol 146: 146-59, 1946. [Context Link]
15. Cross SA, Callaway CW. D-lactic acidosis and selected cerebellar ataxias. Mayo Clin Proc 59: 202-5,
1984. Bibliographic Links [Context Link]
16. Dahlquist NR, Perrault J, Callaway CW, Jones JD. D-lactic acidosis and encephalopathy after
jejunoileostomy: Response to overfeeding and to fasting in humans. Mayo Clin Proc 59: 141-45, 1984.
Bibliographic Links [Context Link]
17. De Vrese M, Koppenhoefer B, Barth CA. D-lactic acid metabolism after an oral load of dl-lactate. Clin
Nutr 9: 23-28, 1990. Bibliographic Links [Context Link]
18. De Vrese M, Barth CA. Postprandial plasma d-lactate concentrations after yogurt ingestion. Z
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 17 of 20
Ernahrungswiss 30: 131-37, 1991. Bibliographic Links [Context Link]
19. De Wind LT, Payne H. Intestinal bypass surgery for morbid obesity. Long term results. JAMA 236:
2298-2301, 1976. [Context Link]
20. Dibner JJ, Knight CD. Conversion of 2-hydroxy-4-(methylthio)butanoic acid to 1-methionine in the
chick. A stereospecific pathway. J Nutr 114: 1716-23, 1984. Bibliographic Links [Context Link]
21. Drury DR. Chemistry and metabolism of 1- and d-lactic acids. Ann N Y Acad Sci 119: 1061-65, 1965.
Bibliographic Links [Context Link]
22. Dunlop RH, Hammond PB. D-lactic acidosis of ruminants. Ann N Y Acad Sci 119: 1109-32, 1965.
Bibliographic Links [Context Link]
23. Duran M, Van Biervliet JPGM, Kamerling JP, Wadman SK. D-lactic aciduria, an inborn error of
metabolism. Clin Chim Acta 74: 297-300, 1977. Bibliographic Links [Context Link]
24. Flourie B, Messing B, Bismuth E, Etanchaud F, Thuillier F, Rambaud JC. D-lactic acidosis and
encephalopathy in short bowel syndrome occurring during antibiotic treatment. Gastroenterol Clin Biol 14:
596-98, 1990. Bibliographic Links [Context Link]
25. Fuller TJ, Garg LC, Harty RF, Cerda JJ. Severe hyperchloremic acidosis complicating jejunoileal bypass.
Surg Gynecol Obstet 146: 567-71, 1978. Bibliographic Links [Context Link]
26. Giesecke D, Fabritius A. Oxidation and excretion of d-lactic acid by rats. Experientia 30: 1124-25,
1974. Bibliographic Links [Context Link]
27. Giesecke D, Wallenberg PV. Metabolism of d-lactic acid in rats given high intragastral doses. Comp
Biochem Physiol 82B: 255-58, 1985. Bibliographic Links [Context Link]
28. Gurevitch J, Sela B, Jonas A, Golan H, Yahav Y, Passwell JH. D-lactic acidosis: A treatable
encephalopathy in pediatric patients. Acta Pediatr 82: 119-21, 1993. [Context Link]
29. Haan E, Brown G, Mitchell D, Hunt S, Blakey J, Barnes G. Severe illness caused by the products of
bacterial metabolism in a child with a short gut. Eur J Pediatr 144: 63-65, 1985. Bibliographic Links
[Context Link]
30. Halperin ML, Kamel KS. D-lactic acidosis: Turning sugar into acids in the gastrointestinal tract. Kidney
Int 49: 1-8, 1996. Bibliographic Links [Context Link]
31. Halverson J, Gale A, Lazarus C. D-lactic acidosis and other complications of intestinal bypass surgery.
Arch Intern Med 144: 357-60, 1984. Bibliographic Links [Context Link]
32. Hartmann AF, Perley AN, Basman J et al. Further observations on the metabolism and the clinical uses
of sodium lactate. J Pediatr 13: 692-714, 1938. [Context Link]
33. Hingorani AD, Macdougall IC, Browne M, Walker RWH, Tomson CRV. Successful treatment of acute dlactate encephalopathy by hemodialysis. Nephrol Dial Transplant 8: 1283-85, 1993. Bibliographic Links
[Context Link]
34. Hove H, Nordgaard-Andersen I, Mortensen PB. Faecal dl-lactate concentration in 100 gastrointestinal
patients. Scand J Gastroenterol 29: 255-59, 1994. Bibliographic Links [Context Link]
35. Hove H, Mortensen PB. Colonic lactate metabolism and d-lactic acidosis. Dig Dis Sci 40: 320-30, 1995.
Bibliographic Links [Context Link]
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 18 of 20
36. Hudson M, Pocknee R, Mowat NAG. D-lactic acidosis in short bowel syndrome. An examination of
possible mechanisms. Q J Med 274: 157-63, 1990. [Context Link]
37. Jover R, Leon J, Palazon JM, Dominguez JR. D-lactic acidosis associated with use of medium-chain
triglycerides [letter]. Lancet 346: 314, 1995. Bibliographic Links [Context Link]
38. Judge MA, Van Eys J. Excretion of d-lactic acid by humans. J Nutr 76: 310-13, 1962. Bibliographic
Links [Context Link]
39. Kadakia SC. D-lactic acidosis in a patient with jejunoileal bypass. J Clin Gastroenterol 20: 154-56,
1995. Bibliographic Links [Context Link]
40. Karton M, Rettmer RL, Lipkin EW. Effect of parenteral nutrition and enteral feeding on d-lactic acidosis
in a patient with short bowel. J Parenter Enteral Nutr 11: 586-89, 1987. Bibliographic Links [Context Link]
41. Koletzko S, Waag KL, Koletzko B. Recurrent d-lactic acidosis with encephalopathy in a boy with short
bowel syndrome. Dtsch Med Wochenschr 119: 458-62, 1994. Bibliographic Links [Context Link]
42. Kuze S, Naruse T, Yamakasi M, Hirota K, Ito Y, Miyahara T. Effects of sodium l-lactate and sodium
racemic lactate on intraoperative acid-base status. Anesth Analg 75: 702-7, 1992. Bibliographic Links
[Context Link]
43. LaManna JC, Harrington JF, Vendel LM, Abi-Saleh K, Lust WD, Harik SI. Regional blood-brain lactate
influx. Brain Res 614: 164-69, 1993. Bibliographic Links [Context Link]
44. Madias NE. Lactic acidosis. Kidney Int 29: 752-74, 1986. [Context Link]
45. Mason PD. Metabolic acidosis due to d-lactate. Br Med J 292: 1105-6, 1986. [Context Link]
46. Mayne AJ, Handy DJ, Preece MA, George RH, Booth IW. Dietary management of d-lactic acidosis in
short bowel syndrome. Arch Dis Child 65: 229-31, 1990. Bibliographic Links [Context Link]
47. Mc Cabe ERB, Goodman SI, Fennessey PV, Miles BS, Wall M, Silverman A. Glutaric, 3hydroxypropionic, and lactic aciduria with metabolic acidemia, following extensive small bowel resection.
Biochem Med 28: 229-36, 1982. Bibliographic Links [Context Link]
48. McNeil A, Walmsley RN. A case of combined d-lactate and renal tubular acidosis [letter]. Clin Chem 30:
1722, 1984. Bibliographic Links [Context Link]
49. Nghiem CH, Bui HD, Chaney RH. An unusual cause of d-lactic acidosis. West J Med 148: 332-34, 1988.
Bibliographic Links [Context Link]
50. Oh MS, Carroll HJ, Goldstein DA, Fein IA. Hyperchloremic metabolic acidosis during the recovery phase
of diabetic ketosis. Ann Intern Med 89: 925-27, 1978. Bibliographic Links [Context Link]
51. Oh MS, Phelps KR, Traube M, Barbosa-Saldivar JL, Boxhill C, Carroll HJ. D-lactic acidosis in a man with
the short bowel syndrome. N Engl J Med 301: 1109-32, 1979. [Context Link]
52. Oh MS, Uribarri J, Alveranga D, Lazar I, Bazilinski N, Carroll HJ. Metabolic utilization and renal handling
of d-lactate in men. Metabolism 34: 621-25, 1985. Full Text Bibliographic Links [Context Link]
53. Oh MS, Uribarri J, Carroll HJ. Electrolyte case vignette: A case of unusual organic acidosis. Am J Kidney
Dis 11: 80-82, 1988. Bibliographic Links [Context Link]
54. Perlmutter DH, Boyle JT, Campos JM, Egler JM, Watkins JB. D-lactic acidosis in children. An unusual
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 19 of 20
metabolic complication of small bowel resection. J Pediatr 102: 234-38, 1983. Full Text Bibliographic
Links [Context Link]
55. Ramakrishnan T, Stokes P. Beneficial effects of fasting and low carbohydrate diet in d-lactic acidosis
associated with short bowel syndrome. J Parenter Enteral Nutr 9: 361-63, 1985. Bibliographic Links
[Context Link]
56. Ravitch M, Brolin RE. The price of weight loss by jejunoileal shunt. Ann Surg 190: 382-88, 1979.
Bibliographic Links [Context Link]
57. Reynolds AF, Villar HV, Kasniak AW. Jejunoileal bypass: A reversible cause of dementia. Neurosurgery
9: 153-55, 1981. Bibliographic Links [Context Link]
58. Rosenthal P, Pesce M. Long-term monitoring of d-lactic acidosis in a child. J Pediatr 4: 674-76, 1985.
[Context Link]
59. Satoh T, Narisawa K, Konno T, Katoh T, Fujiyama J, Tomoe A, Metoki K, Hayasaka K, Tada K, Ishibashi
M, Yamane N, Mitsuoka T, Benno Y. D-lactic acidosis in two patients with short bowel syndrome.
Bacteriological analyses of the fecal flora. Eur J Pediatr 138: 324-26, 1982. Bibliographic Links [Context
Link]
60. Schoorel EP, Giesberts MAH, Blom W, Van Gelderen HH. D-lactic acidosis in a boy with short bowel
syndrome. Arch Dis Child 55: 810-12, 1980. Bibliographic Links [Context Link]
61. Scully TB, Kraft SC, Carr WC, Harig JM. D-lactate-associated encephalopathy after massive smallbowel resection. J Clin Gastroenterol 11: 448-51, 1989. Bibliographic Links [Context Link]
62. Smith SM, Eng RHK, Buccini F. Use of d-lactic acid measurement in the diagnosis of bacterial infection.
J Infect Dis 154: 658-64, 1986. [Context Link]
63. Spillane K, Nagendran K, Prior PF, Tabaqchali S, Wilks M. Serial electroencephalograms in a patient
with d-lactic acidosis. Electroencephalogr Clin Neurophysiol 91: 403-5, 1994. Bibliographic Links [Context
Link]
64. Stolberg L, Rolfe R, Gitlin N, Merritt J, Mann L, Linder J, Finegold S. D-lactic acidosis due to abnormal
gut flora. Diagnosis and treatment of two cases. N Engl J Med 306: 1344-48, 1982. Bibliographic Links
[Context Link]
65. Thornalley PJ. The glyoxalase system: New developments towards functional characterization of a
metabolic pathway fundamental to biological life. Biochem J 269: 1-11, 1990. Bibliographic Links [Context
Link]
66. Thurn JR, Pierpont GL, Ludvigsen CW, Eckfeldt JH. D-lactate encephalopathy. Am J Med 79: 717-21,
1985. Bibliographic Links [Context Link]
67. Traube M, Bock JL, Boyer JL. D-lactic acidosis after jejunoileal bypass: Identification of organic anions
by nuclear magnetic resonance spectroscopy. Ann Intern Med 98: 171-73, 1983. Bibliographic Links
[Context Link]
68. Tubbs PK. The metabolism of d-alpha hydroxy acids in animal tissues. Ann N Y Acad Sci 119: 920-26,
1965. Bibliographic Links [Context Link]
69. Ullrich KJ, Rumrich G, Kloss S. Reabsorption of monocarboxylic acids in the proximal tubule of the rat
kidney. Transport kinetics of d-lactate, Na-dependence, pH-dependence and effects of inhibitors. Pflugers
Arch 395: 212-19, 1982. Bibliographic Links [Context Link]
70. Van Eys J, Judge A, Judd J, Hill W, Bozian RC, Abrahams S. A reinvestigation of methylglyoxal
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006
Ovid: Uribarri: Medicine (Baltimore), Volume 77(2).March 1998.73-82
Page 20 of 20
accumulation in thiamine deficiency. J Nutr 76: 375-83, 1962. Bibliographic Links [Context Link]
71. Yasuda T. D-lactate metabolism in chronic renal failure. St Marianna Med J 16: 593-605, 1988. [Context
Link]
72. Yasuda T, Ozawa S, Shiba C, Maeba T, Kanazawa T, Sugiyama M, Owada S, Ishida M. D-lactate
metabolism in patients with chronic renal failure undergoing CAPD. Nephron 63: 416-22, 1993.
Bibliographic Links [Context Link]
Accession Number: 00005792-199803000-00001
Copyright (c) 2000-2006 Ovid Technologies, Inc.
Version: rel10.2.2, SourceID 1.11354.1.251
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
5/1/2006